386559_Well Construction - GW1_20100901

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NON ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Dtvis,on of Water Quahty
WELL CONTRACTOR CERTIFICATION # 3 5 5-
1. WELL CONTRACTOR:
C. 4tGLr ( 1 ; C-UtD(
Well Contractor (Individual) Name
t /m. e/ 7? co 5 .
Well Contractor Company Name
STREET ADDRESS 67on
C c/e tie
City or Town State Zip Code
(7O)- 3°(a1- /jU ,
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable)
STATE WELL PERMIT#{rf applicable) /
DWQ or OTHER PERMIT #(if applicable) /D 0 Q t 6 /p
WELL USE {Check Applicable Box) Monitonng ❑ Municipal/Public ❑
Industnal/Commercial ❑ Agncultural 0 Recovery 0 Injection 0
Irngatior)Other ❑ (list use)
DATE DRILLED 7 -- J 0
TIME COMPLETED 3 O p AM ❑ PM Pk"'
3. WELL LOCATION. �//11
CITY l �TGt r (o -I-(e COUNTY "l c r t.
/ 3 3-2 5 3 --r y 54'. 22a75r
(Street Name. Numbers, Community, Subdivision, Lot No , Parcel, Zip Code)
TOPOGRAPHIC / LAND�SETTING
DSlope DValley ,eoriat ❑Ridge 0 Other
(check appropnate box)
LATITUDE 3 (7 O S.73c
LONGITUDE e D° 57.6 v9 -
May be in degrees,
minutes, seconds or
in a decimal fomiat
Latitude/longitude source: 'GPS oTopographic map
(location of well must be shown on a USGS topo map and
attached to this form rf not using GPS)
4. FACILITY -is the name of the business where the well Is located
FACILITY ID #(it applicable)
NAME OF FACILITY w1 `56 0 1 ®S
STREET ADDRESS / 3 32 S S
�Gluf/Ei77g-e•
City or Town State Zip Code
CONTACT PERSON L -T36 tit 0.5
MAILING ADDRESS / 43.2 LI 7"r k 12.40
C'-t',p,•16 k /U. c.
City or Town State
( 9C) )- (2 ')' — co(/ i r/
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 110 0
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑
c. WATER LEVEL Below Top of Casing.
(Use "+" if Above Top of Casing)
NO -
FT.
3; .559
d. TOP OF CASING IS 1 ' `7 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a vanance in accordance with 15A NCAC 2C 01^18.
e. YIELD (gpm) -30O METHOD OF TES;
f c'^�
f. DISINFECTION: Type - T µ' Amount 14- O›.-
g. WATER ZONES (depth)crz 3C W,w.
From3Fl5- To3auo—From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Matenal
From C) To 3 `/ Ft lD /e- S.A ?roo PVC
From To Ft.
From To Ft
7. GROUT: Depth
Matenal Method
From 0 To.2C7 Ft .4/e,c4<-0.,,,t
From To Ft
From To Ft
8. SCREEN: Depth Diameter Slot Size Material
From//4 To Ft In in
From To Ft. in. in.
From To Ft. in. in,
9. SAND/GRAVEL PACK:
Depth Size Material
FromTo Ft
From To Ft.
From To Ft,
10. DRILLING LOG
Flom .2 y o d orrna iron e�sc�nphon
-Oi24;tr
1- - r/Oct
11. REMARKS:
Grey Roc 4_
5tr 1 — ?tilt]
.wirridsian Processing Unit
uvvt.,Ut3UCi
Do HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AN THAT A COPY OF THIS
RECORD BEE PROW) TO THE WE NER�
��� -- 7- -/p
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
c f;,ar (;< ?JaLc($
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 668.
Form GW-lb
Rev 7/05